Carlson, Frances NEW YORK STATE DEPARTMENT OF HEALTH t
Vital Records Section Burial - Transi ermit
Name First Middle Last Sex
Frances Carmen Carlson Female
Date of Death Age If Veteran of U.S.Armed Forces,
June 3, 2016 90 War or Dates
OPlace of Death Hospital, Institution or
Ci .4019,.r Village Colonie Street Address Loudonville Assited Living
W Manner of Death L Natural Cause ❑ Accident ❑Homicide❑ Suicide ❑Undetermined ❑ Pending
Circumstances Investigation
W Medical Certifier ,}Name /1 Title
Kr,+"1c\2 l,tJ.n faq Thr
Address J
.7/3 iwo-sd�,,e,,,c.<. �d 'th ivy, /Z/l
• Death Certificate led District Number Register N ber
City, Tor Village Colonie /o�� 4
0 Burial Date Cemetery or Crematory
June 6, 2016 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date Place Removed
z ❑ Removal and/or Held
0 and/or Address
Hold
0.0 Date Point of
❑Transportation Shipment
N by Common Destination
G Carrier
Date Cemetery Address
El Disinterment
Date Cemetery Address
❑ Reinterment
Permit Issued to Registration Number
Name of Funeral Home M.B. Kilmer Funeral Home-SGF 01078
Address
136 Main Street, South Glens Falls NY 12803
Name of Funeral Firm Making Disposition or to Whom
L Remains are Shipped, If Other than Above
2 Address
CC
tL Permission is he7bpanted y to dispose of the human ,ains d scri ed aq r s� i d,is ed.
Date Issued P p Registrar of Vital Statistics L/C� ' 'u�C
(signature)
District Number /5 Place erg��
,3
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
w Date of Disposition 06/06/2016 Place of Disposition Quaker Road Queensbury,NY 12804
2 (address)
W
Co
0 (section) (lot number (grave number)
p Name of Sexton or Person in Charge f Premises �h� ._ ,,Firms'
z ( lease print)
W Signature Zi Title P4-
(over)
DOH-1555(02/2004)